The URL can be used to link to this page

Home My WebLink AboutWire Permit - Permits #13044 - 430 OSGOOD STREET 1/6/2015 ti Si O \� �-' Date......,..� �.......... 010 \\ o �pRT#q ME OF NORTH TOW .Q , mm PERM ;�``} ;`• IT FOR WIRING ISO � ME �� gm \ El"s a',as MENIMI Sol Im MM ME- This certifies that ... .. . ........... � SEEM sign to rfc� ... gp .. ....,.e .. ...... EM has pen s p ............... ........................................ IME wiring in the building cif _ \ M .. ........... p nave , ass. at ........ �... ......,,. �� r 17011 ... ic. Igo. .......... . ..: MEaNmIN .,,...�.. mom E��cTlzlc�� INSFECTCIR Fee...... . . \ M M Cheek �� gag \\ %�/��/�%�Gl�%�/IT�G/�(//I%//��11%/(/Gf0�0��OG%�G%/i�%/�iG/�G///%��rl�liriU�i�%ii�ii/iiii/ire/rr ri " ; �fr�/O�t�r��GrrG�/rr�6Gril%/��l/�ir0/G/�rj�//i/��i6r/rr�G/i/rrr�rrr(��rrrdrrr6�rro0n�(6r/i///Gi�/irrr/rrGrr�irrl/i1/rrrii/iO�//�%/i%%/di%G7/�rlr�(�r/iGi/ r, / t: fir, �, ,� �� i ti 6- µ 1 f i �' r S r% J j, i`' ys !% �r �I��J�l��)II�J��)��JJ))J�11J��Jl"I1%�jll�%"l��'��)'Ir�lJ��JI)l�I��l)y�l��)1��r1��J��1��1��1�>>�»�,� ,, /�� .��1)/lii��ll�/�111;1�11)'I��1�J')Jm��i�i�l�ll��)',�'9��JJ'y�J��ll�)�l��l��II��Jl�)��"II11111��1» �� Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Date Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: January 5, 2015 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 430 Osgood Street Map: Lot: Owner or Tenant -High School Telephone No. 978-794-1711 Owner's Address same Is this permit in conjunction with a building permit? Yes El No Z (Check Appropriate Box) Purpose of Building I Utility Authorization No. Existing Service _ Amps —Volts OverheadF] Undgrd ❑ No.of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Repair of site lighting in parking lot.Replace lamps. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above Ei In- El No.of Emerg ncy Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons..........J.KW........... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal Fj Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters I Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OT*HER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licen- see provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND F-1 OTHER ❑ (Specif I certify,under the pains and penalties of perjury,that the inform n this application is true and complete. FIRM NAME: Andover Electric Services, Inc E LIC.NO.: 14302 Licensee: Robert J. Branca Signa re LIC.NO.: *Per M.G.L. c. 147,s. 57-6 1,security work requires Dep to Public Safety"S"License: LIC.NO.:"S: (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 978-475-4995 Address: 19 Dale St, Andover, MA Zip: 01810 Alt.Tel.No.: 978-423-8350 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)F-1 owner F-1 owner's agent. Ow Signature Fee: Ivu T/A�,ent) Phone: Fold,"Phan Debwh AMwV AN Perforsdoin T i pr • **• i • • 01 a. Fold,Then Detach Along All Ntfo^ratlon% rs. ,« s STATE.OF pHI HAAAPS`iHIRI C ` ICIMS.,BOARD Via. .. NAME: Ft0 M� ° 06 1 M w EXPIRES.: 1 The Commonwealth of Massachusetts Department of Industrial Accidents A Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-201 T www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Inc. Name (Business/Organization/Individual): Andover Electric Services, _ Address: 19 Dales Street City/State/Zip:Andover, MA 01810 Phone #:978-475-4995 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 5 4. I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. F] Remodeling ship and have no employees These sub-contractors have 8. n Demolition workingfor me in an capacity. employees and have workers' y9. ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other camp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:The Hartford Policy#or Self-ins. Lic. #:08 WEC CM5940 Expiration Date:4/28/15 Jab site Address: 430 Osgood Street City/State/Zip:North Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for incur' e coverage verification. I do hereby certify underlie p ns and penalties of perjury that the information provided above is true and correct. Si mature: Date: January 5, 2015 Phone#: 97 475499 - ' Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: TE AL V` CERTIFICATE OF LIABILITY INSURANCE DA04/28/201 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. HIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED LtEPRESENTATIVE OR PROQUCER,AND THE CERTIFICATE IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone: (978)474-0810 Fax: (978)474-0890 CONTACT NAME: Sandal Insurance Agency,Inc. JONATHAN M SAMEL CIC LIA _� . `C Ns..Ex);..__978-474-0810 F Nol: 978.474.0890 _._.._._._... SAMEL INSURANCE AGENCY,INC. E-MAIL info@samel•ins.com ADDRESs 15 CENTRAL STREET -----------...__— PRODUCER ANDOVER MA 01810 CUSTOMERID: 12� _ INSURER(S) AFFORDING COVERAGE NAIC M INSURED INSURER Sentinel insurance Co,LTD — 11000 ANDOVER ELECTRIC SERVICES INC PO BOX 629 INSURER B :Citation Insurance Company 40274 ANDOVER MA 01810 1 SURER :Sentinel Insurance Co,LTD 1100 INSURERD: Hartford Fire Insurance Company 19682 INSURER E COVERAGES CERTIFICATE NUMBER: 39153 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, INSR TYPE OF INSURANCE ADO'L SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER — MWpgrP/YV MMIDD _ A GENERAL LIABILITY OBSBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE _$__ 2,000,000 X COMMERCIAL GENERAL LIABILITY OHMAGES(TO RENTED $ 1,000,000 _ _ � PREMISES�ursnceL_.._.._.__ _..�---... CLAIMS-MADE I 1' 'OCCUR MED_EXP(Any one person) $ 10,000 — PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG g 4,000,090 POLICY X PRO- LOG $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT KYV7918 03/23/14 03123/15 $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS _ — BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE -- $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS C X UMBRELLA LWB X OCCUR 08SBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE 2,000 000 ExcEBs LIAS CLAIMS-MADE AGGREGATE 2,000,000 DEDUCTIBLE X RETENTION $ 10 000 _ $ D '11ORYER. COMPENSA wON 08WECCM594O 04f28114 04128/15 X T�c T� -� oTN $ AND EMPLOYERS' LIABILITY Y/N _._L-._TORY LIMITS _ .._—_ ANY PROPRIETORIPARTNERIEXECUTNE I— E.L.EACH ACCIDENT _ 500,0911 OFFICER/MEMBER EXCLUDED? N NIA (Mandatory In NH) E.L.DISEASE EA EMPLOYEE — 500,0(W 1,yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is required) Operations typical to commercial and residential electrical contractor. CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Attention: " Jonathan M.Samel ACORD 25(2009/09) 0 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD